Figure 2 - Plain film radiograph of a supracondylar fracture in lateral view Gartland Classification Displacement of the anterior humeral line (in children >5yrs, this should intersect the middle third of the capitellum)ĬT imaging may be useful for comminuted fractures or where intra-articular extension is suspected, which aides with surgical planning.Posterior fat pad sign (lucency visible on the lateral view). Subtle signs on plain film radiograph for a supracondylar fracture include: The mainstay of investigation for suspected supracondylar fractures is via plain film radiographs in both antero-posterior (AP) and lateral views of the elbow. Other differentials include soft tissue injury or a subluxation of the radial head. Differential Diagnosisĭistal humeral fractures and olecranon fractures are important fractures to exclude, as management of these can vary significantly. Urgent orthopaedic review is required for all supracondylar fractures, especially those with neurovascular compromise or evidence of an open fracture. It is essential to carefully examine the median nerve, the anterior interosseous nerve (the deep motor branch of the median nerve), the radial nerve, and the ulnar nerve.Ĭheck the hand for features of vascular compromise, such as a cool temperature, pallor, delayed capillary refill time, or absent pulses. Ensure to look closely for evidence of an open injury. On examination, there may be signs of gross deformity, swelling, limited range of elbow movement (secondary to pain), and ecchymosis of the anterior cubital fossa. Patients typically present following a recent fall or direct trauma, resulting in sudden-onset severe pain and reluctance to move the affected arm. Draw a Radiocapitellar Line, to exclude a radial head dislocation.Figure 1 – Bony landmarks of the distal humerus Clinical Features.Draw an Anterior Humeral Line, to assess joint alignment.If there is a positive fat pad sign but no fracture seen in an adult, think of a radial head fracture.If the patient presents with clinical signs of a fracture and the x-ray is normal, treat them like there is a fracture.My 4 Rules for reviewing the elbow X-ray to not miss any. We know the patient had a radial head fracture. It tells us there is normal alignment of the joint, but doesn’t tell us about a fracture. Both the anterior humeral line and the radiocapitellar line pass through the centre of the capitellum. The line passes parallel to the neck of the radius. It should pass through the capitellum in all views One of the common mistakes, is to draw the line parallel to the shaft of the radius and not to the neck of the radius. It should pass through the centre of the capitellum. This is a line drawn through the centre of the radius, running parallel to the neck of the radius. It is a helpful line as it identifies radial head dislocation. In a supracondylar fracture this can occur due due posterior displacement of the distal humerus.īeware in children less than 4 years of age there may be false negatives. If it doesn’t pass through this point then there is abnormal alignment of the elbow joint. In the normally aligned joint, it should pass through the middle third of the capitellum. The anterior humeral line, assists us in identifying normal elbow alignment but also in diagnosing a supracondylar fracture in children.Ī line is drawn along the anterior surface of the humerus. HINT 2: If there is a positive fat pad sign but no fracture seen in an adult, think of a radial head fracture, it will be there. Its obvious that there is a sail sign, but there is no obvious fracture. This is a 32 yo woman who fell off her bicycle and landed on her elbow, presents with pain in the elbow and limited movement. However when it is so displaced by an effusion as to result in the ‘sail sign’ or when you see the posterior fat pad, it is a good marker for a fracture. You might normally see the anterior fat pad. If you can see a fat pad, it simply indicates a joint effusion. What are the X-ray Signs? The Fat Pad Sign HINT 1: If the patient presents with clinical signs of a fracture and the x-ray is normal, treat them like there is a fracture. A fracture can occur with a normal X-ray. The x-ray merely confirms that you have found it. How good are you at reading elbow X-rays? Here are some tools and rules that will help you pick up those elbow fractures.įractures of the elbow usually fall into the following groups:įractures are a CLINICAL Diagnosis.
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